Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
An innovative program supporting people with disability to transition into community living was implemented and evaluated to assess impact and guide refinement.
Dates: Mar 2024 - Feb 2026
Implementation sites: Gold Coast University Hospital and Robina Hospitals
Partners: Multicap (H2C Program) and Summer Foundation (Research)
Aim
To implement and evaluate an innovative model of care that aimed to improve timely discharge and care coordination for people under 65 with disability and complex needs experiencing prolonged hospital stays, informed by stakeholder experience.
Outcomes
The H2C pilot improved discharge efficiency and cross-system integration for people with disability and complex needs, while remaining cost neutral for the health service. During the pilot period (March 2024-June 2025), 47 patients were successfully discharged from Gold Coast Health hospitals through the H2C program. The H2C program achieved an average saving of 50 bed days per patient, resulting in significant reductions in extended length of stay and more equitable outcomes for our most vulnerable patients. Stakeholders reported largely positive experiences, highlighting improved navigation across health and disability systems, enhanced continuity of care, sustained discharges, stronger alignment of supports to patients'' needs, improved quality of life and decreased caregiver burden.
Background
People with disability and complex support needs experience prolonged stays in Australian hospitals after being medically ready for discharge. These delays are associated with prolonged National Disability Insurance Scheme (NDIS) processes and the complexity of arranging appropriate housing, equipment, and community-based supports. In 2022, approximately 1,140 people with disability across Australia experienced extended hospital stays while awaiting housing or community supports, highlighting the scale of this problem (Summer Foundation, 2022).
Extended hospital stays for people with disability is frequently driven by poor integration between acute health services, the NDIS, and community service providers (Foster et al., 2020; Houston et al., 2020; Summer Foundation, 2021). These challenges are particularly pronounced for NDIS participants awaiting accommodation funding, specialised housing, essential equipment, and ongoing community supports (Cubis et al., 2022). Difficulties in securing appropriate long-term housing also compound the delays (Summer Foundation, 2022).
The consequences of extended hospital stays are significant for patients and their families. Prolonged admission is associated with deterioration in physical function and overall health status, alongside an increased risk of hospital-acquired complications. Extended stays also contribute to heightened psychological distress for patients and families and reduce quality of life (Rojas-Garca et al., 2018). Acute wards are not designed for complex disability-related needs, and may lack appropriate environments and support models, leading to increased distress, behavioural escalation, and safety incidents that further delay discharge.
The impact of delayed discharge extends beyond the individual to place substantial pressure on the hospital and health system. Extended length of stay contributes to increased costs, reduced availability of acute beds, and delays in admitting other patients. Flow-on effects include increased reliance on system interventions to manage discharge delays, cancellation of elective surgeries, and longer waiting times for ambulances (Commonwealth of Australia, 2023; Rojas-Garca et al., 2018). Health workers also experience increased workload and moral distress when caring for patients who remain hospitalised due to non-clinical barriers (Summer Foundation, 2021).
Local data identified that patients under 65 years with disability and complex support needs at Gold Coast Hospital and Health Service (GCHHS) were experiencing unnecessary extended lengths of stay, consistent with national trends. In response, targeted funding was provided to pilot a new discharge model of care. The Hospital to Community (H2C) program was established as a partnership between GCHHS and an external disability service providers to support safe, timely, and person-centred discharge for patients who were medically ready to leave hospital but unable to do so due to unmet non-acute support needs.
Piloted between March 2024 and June 2025, the H2C program funded up to three months of tailored, community-based transition support delivered by NDIS providers and funded by the health service. This support model aimed to bridge the gap between hospital care and the establishment of longer-term NDIS-funded supports, enabling individuals to return to community living while longer-term arrangements were finalised.
The project addressed a critical system problem: the absence of coordinated, cross-sector discharge solutions for people with disability, despite clear evidence of the personal, clinical, and system-level consequences of extended hospitalisation.
Methods
The Hospital to Community (H2C) program was piloted at GCHHS between March 2024 and June 2025 to support timely, person-centred discharge for patients with disability and complex support needs. A competitive dialogue process was used to establish a partnership with a community disability provider, and the model of care was co-designed through joint governance, operational workshops, and iterative process development, as no existing models were available to guide program logic.
Program implementation included defining the target population, establishing the program team, and engaging with patient clinical teams through information sessions and stakeholder meetings. Key initiatives developed and implemented included standardised referral pathways, role delineation between hospital and provider teams, structured patient onboarding processes, escalation and clinical governance protocols, and a communication framework to support coordination between hospital staff, the community provider, patients, and significant others. Processes were developed to streamline inpatient-to-community discharge workflows, align existing community supports, reduce role duplication, and clarify responsibilities across organisations. Targeted documentation templates and workflows were introduced to enable the community provider to evidence functional need for the NDIS supports. Workforce capability was supported through consolidating tools and education resources designed to minimise additional documentation and training burden for acute inpatient teams. A standardised handover pathway was established to support transition from H2C to community and NDIS-funded services and ensure continuity of care.
Implementation was guided by a continuous quality improvement approach using iterative Plan-Do-Study-Act cycles (Langley et al., 2009) with regular joint meetings and two formal "Barriers and Solutions" workshops to identify and address implementation challenges. Key refinements included onboarding checklists, improved invoicing and equipment provision processes, strengthened linkage with community supports (including nursing, allied health, support coordination and Centrelink), increased on-site provider coordination in the hospital, and appointment of a dedicated HP4 H2C coordinator in the health service to enhance discharge planning and cross-sector communication.
Weekly joint patient review meetings supported ongoing care coordination. Recognising that many patients had experienced traumatic health events and prior negative interactions with health and disability systems, structured trust-building strategies were implemented, including early relationship-building sessions, transparent communication of program expectations, patient and family education materials, and regular check-ins. Feedback mechanisms were used to iteratively adapt program delivery. A mixed-methods evaluation was embedded alongside implementation. Quantitative administrative data were used to examine length of stay, bed days saved, and program costs. Qualitative data were collected through semi-structured interviews with hospital staff, community providers, patients, and support people to explore implementation experiences, barriers, enablers, and improvement opportunities. As research data were being collected and analysed, findings were regularly presented to GCHHS Executive, the research reference group, clinicians and H2C staff from both health and disability organisations to guide ongoing refinements.
The integrated implementation and research facilitated iterative refinement of the program, embedding continuous improvement cycles and generating practical insights.
Discussion
The H2C pilot demonstrates that successful implementation of hospital-to-community transition programs relies on executive support, robust cross-sector partnerships, dedicated staffing, and engaged clinical teams. Executive commitment, including sustained funding and governance oversight, was foundational to timely decision-making for funding approval, efficient resource allocation, and program accountability. Experienced program leadership, coupled with active clinician engagement, facilitated appropriate patient identification and streamlined referral pathways, ensuring that patients with complex needs were supported throughout their transition.
A public-private partnership was central to the program''s success. Shared goals, aligned values, and co-designed workflows fostered trust between hospital and community partners and supported continuous evolvement of the program. However, collaboration across sectors required sustained negotiation and relationship building, particularly in relation to workforce roles and responsibilities, scope of practice, and the transferability of care plans across settings.
Early and ongoing stakeholder engagement, combined with the recruitment and presence of dedicated program staff, supported program uptake and operational stability. Dedicated staff in roles identified as crucial throughout the early parts of program implementation was a facilitator of program success. Consolidation of documentation and processes reduced duplication, and improved communication, and cross-sector coordination. Structured, data-driven monitoring enabled iterative refinement of key program processes, including referral pathways, care coordination mechanisms, equipment provision, and invoicing. Availability of appropriate accommodation, support workers, assistive equipment, allied health services, and community nursing emerged as critical enablers of the program. Core program components such as dedicated staffing, flexible funding arrangements, governance structures, structured processes, stakeholder engagement, and cross-sector collaboration, are transferable to other populations and care contexts.
The navigator role was identified as a critical mechanism for bridging hospital and community care contexts, supporting patients and clinicians to navigate complex systems and ensure continuity of care. Clear delineation of responsibilities between hospital-based staff and community provider support coordinators was necessary to streamline transitions. Community-based evidence generation of functional capability was particularly valuable in supporting NDIS processes, enabling needs-based care planning, and facilitating sustainable discharge outcomes and living arrangements. These crucial program components above mean that the H2C model could be applicable to other tertiary hospitals in metropolitan areas with similar patient demographics and where delayed discharge and fragmented community supports are also prevalent. Across regional and rural sites, access to support services and suitable accommodation is a significant barrier to discharge and therefore may impact applicability to these contexts.
The extension of the H2C program to June 2027 provides an opportunity to further assess sustainability, scalability, and system impact over time. Future program iterations may benefit from the inclusion of dedicated allied health roles as part of the hospital team to reduce the burden on ward-based teams and accelerate discharge processes. Additionally, engaging multiple community providers with expertise in different disability and complex care needs would strengthen service responsiveness and resilience.
References
Commonwealth of Australia. (2023). Working together to deliver the NDIS - Independent Review into the National Disability Insurance Scheme: Final Report. Retrieved from https://www.ndisreview.gov.au/resources/reports/working-together-deliver-ndis
Cubis, L., Ramme, R. A., Roseingrave, E., Minter, E., Winkler, D., & Douglas, J. (2022). Evaluating the discharge planning process: Barriers, challenges, and facilitators of timely and effective discharge for people with disability and complex needs. Melbourne: Summer Foundation Retrieved from https://www.summerfoundation.org.au/resources/evaluating-the-discharge-planning-process-barriers-challenges-and-facilitators-of-timely-and-effective-discharge-for-people-with-disability-and-complex-needs/
Foster, M., Borg, D. N., Houston, V., Ehrlich, C., Harre, D., Lau, G., & Geraghty, T. J. (2020). Policy Options: READY Study, Readying hospitalised patients with disability who need NDIS supports for discharge. https://www.hopkinscentre.edu.au/project/ready-study-readying-hospitalised-patients-with-127
Houston, V., Foster, M., Borg, D. N., Nolan, M., & Seymour-Jones, A. (2020). From Hospital to Home with NDIS Funded Support: Examining Participant Pathway Timeframes Against Discharge Expectations. Australian Social Work, 73(2), 175-190. https://doi.org/10.1080/0312407X.2019.1684530
Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. (2nd ed.). Jossey-Bass.
Rojas-GarciÌa, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2018). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 21(1), 41-56. https://doi.org/10.1111/hex.12619
Summer Foundation. (2021). Hospital Discharge of NDIS Participants with High and Complex Needs. Policy Position Statement by the Summer Foundation. https://assets.summerfoundation.org.au/pdf_offload/2021/12/Hospital_Discharge_Position_Statement.pdf
Summer Foundation. (2022). People with Disability Stuck in Hospital May 2022. https://assets.summerfoundation.org.au/pdf_offload/2022/05/PWD-Stuck-in-Hospital-Summary-May-2022-.pdf
Key contact
Melanie Cole
Allied Health Clinician Snr NDIS LOS
Gold Coast Hospital and Health Service